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Tackling COVID with paper, pen and a fax machine

January 27, 2021

The painfully slow digitalization of Germany's health care system has long been a source of frustration. But the inefficiency is hampering attempts to fight the pandemic.

Health Ministry workers answer calls and take notes
Many health authorities still use pen and paper and fax machines to collate dateImage: Britta Pedersen/dpa/picture alliance

Whether it's Ebola, monkeypox, Lassa fever or meningococcus, for years, epidemics in Nigeria and Ghana have been fought with German software. "Surveillance Outbreak Response Management and Analysis System," or SORMAS, is the name of the networked system for contact tracing and recording infection hotspots that epidemiologists at the Helmholtz Centre for Infection Research (HZI) in Braunschweig developed when Ebola was raging in West Africa in 2014.

The system, which is largely automated, has now been modified and matured to the point where it can be used to combat 37 infectious diseases, including COVID-19. Switzerland and France, and also Fiji, are using SORMAS to combat the coronavirus. Burkina Faso, Ivory Coast, Nepal and Afghanistan are also preparing to deploy it.

German health authorities say no thanks

The Helmholtz Institute adapted the software for the German health service in May 2020, but the program designed to aid contact tracing and break infection chains has not been a big seller in the country of its inventors: It has so far only been installed in 132 of just under 400 municipal health offices.

A lot of time and manpower is lost in health departments because most still work with handwritten lists and printed Excel spreadsheets. Data is often transmitted on paper by fax and then manually typed into the computer. In the early days of his term in office, German Health Minister Jens Spahn remarked that in no other area is as much faxing done as in the healthcare sector. But he is no longer in the mood for jokes now.

A man in a German military uniform assesses data on a computer screen
German health authorities are wasting time and manpower with outdated systemsImage: Stefan Sauer/dpa/picture alliance

Spahn earmarked €50 million ($60 million) in the short term for the digitalization of health offices in 2020. In addition, they were allowed to access SORMAS free of charge if they wanted to. However, the minister cannot force them to.

"The responsibility for equipping the health authorities and thus the decision on the use of digital tools lies with the states and the health offices themselves," a spokeswoman for the ministry said.

The situation is different when it comes to the digital connection and networking of doctors, hospitals and laboratories with the health authorities and the Robert Koch Institute (RKI, the German government's central health authority). There, the conversion to DEMIS, the German Electronic Reporting and Information System for Infection Prevention, is in full swing. Spahn ordered that notifiable disease findings and data may only be transmitted electronically. The fax has had its day, according to the minister.

Conflicting infection figures

But of course it's not quite that simple. It is true that 97% of public health departments are now equipped with DEMIS – but only with a slimmed-down version that is still in its test phase. And the RKI is not yet fully integrated into it.

Angela Merkel with Jens Spahn at a cabinet meeting
The federal government has limited influence on how the states administer healthImage: Markus Schreiber/REUTERS

Only some of the laboratories can transmit coronavirus test results electronically to those involved. Most of the data ends up at the health offices electronically, but still also by fax, and must be forwarded from there to the RKI. But the RKI uses its own software for this purpose: SURVNET.

In recent weeks, thousands of reports have been left because health departments have been busy dealing with contact tracing, leaving little time to transfer infection counts to SURVNET. And to make the storm perfect: The health offices not only provide the RKI with the infection figures, but also the administrations at the county and state level. But they then sometimes also send the data by e-mail. As a result, the RKI repeatedly reports different infection figures in its daily situation report than the administrations of the cities, municipalities or federal states.

The consequences of backwardness

The federal government also struggles with the unreliable reporting system. Because the health offices are closed on weekends, the data on Mondays is basically incomplete. The closure between Christmas and New Year also had extreme consequences. When the chancellor and the prime ministers discussed extending the lockdown at the beginning of the year, they had to admit that there was no reliable data with which to judge the incidence of infection in Germany. According to the chancellor, the piled-up reports would not be processed until mid-January at the earliest. But even now, some health offices have not yet worked through the backlog.

A man points to a large screen
Not all the states use the same software systems in their health officesImage: Britta Pedersen/dpa/picture alliance

During the lockdown, there has been a controversial debate about how far infection levels must fall before stores, restaurants and theaters can reopen. The upper limit repeatedly cited is 50 new infections per 100,000 inhabitants within seven days. A figure that is not based on scientific principles, but is oriented around the "average performance of a health department," as Chancellor Angela Merkel recently confirmed.

This performance could be improved with the right digital equipment. That's why in November the chancellor appealed to the state premiers of the federal states to use SORMAS to deploy a nationwide, joint contact tracing system as quickly as possible. An agreement was reached on the target date of early January 2021, but nothing came of it, partly because individual states have already taken their own paths.

Rhineland-Palatinate, for example, has purchased the software MIKADO, which was developed by a company based in Kaiserslautern, i.e. in its own state. It is not compatible with SORMAS. Merkel had to concede a few days ago that the nationwide installation of uniform software "unfortunately did not succeed" because some states preferred "other equivalent systems."

All states have promised to install SORMAS by the end of February. But that doesn't mean it will be up and running immediately. "We can't switch from MIKADO in Rhineland-Palatinate to the use of SORMAS in the desired format now, in the middle of the greatest stress that the health offices are experiencing," said Merkel, who plans to "stay in conversation with the health offices" and keep showing them the advantages of a uniform digital system.

In other words, it will probably take a little longer before Germany can combat the COVID pandemic as digitally as Nigeria did in 2017, when it had three separate outbreaks at the same time.

The article was translated from German.

SHIFT – Living in the Digital Age